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As bipolar disorder is a mental disorder particularly associated with elevated risk of suicide compared to the general population, with reviews suggesting standardized mortality ratios of above 20 and a large population-based study reporting a mortality ratio of 15, one might expect that the combination of imprisonment and the presence of bipolar disorder might be additive or even multiplicative in terms of suicide risk. The previous systematic review did not specifically examine the association between bipolar disorder and prison suicide and thus it remains uncertain if bipolar disorder is a particular risk factor for suicide and suicidal behavior in prisoners. From a public health perspective, the issue is important as the absolute numbers of prisoners with bipolar disorder is large. A recent investigation of routinely collected data on over 200000 sentenced prisoners in Texas reported a prevalence of 2.6%, similar to the 2.8% estimated in an interview-based study of over 1000 prisoners in Italy. Thus, using conservative estimates, at least 100000 individuals with bipolar disorder currently reside in prisons worldwide. Therefore, we report a systematic review investigating the association between bipolar disorder and suicide in prisoners.


To examine the risk of suicide and suicide attempts in prisoners with bipolar disorder and other psychiatric disorders compared with prisoners without psychiatric disorders.


We conducted a systematic review and meta-analysis of observational studies comparing suicide outcomes in prisoners with bipolar disorder and other psychiatric disorders to other prisoners.


Five studies reported the risk of suicidal outcomes in prisoners with bipolar disorder compared with other prisoners, with a random effects pooled odds ratio of 2.4 (95% confidence interval: 1.6–3.7; I2 = 0%). This appeared to be lower than the risk of suicidal outcomes for all psychiatric disorders and for depression, specifically, and, in meta-regression, significantly lower (p = 0.03) than for schizophrenia-spectrum disorders.


Although bipolar disorder is associated with suicide and non-fatal suicidal behavior in prisoners, further research is necessary to confirm any associations and mediating mechanisms.

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Fazel S, Wolf A, Geddes JR. Bipolar Disord. 2013 Aug;15(5):491-5.